APTUS® Elbow Elbow System 2.0, 2.8

Transcription

Su r gi c al T ec hni q ue – S tep by step
Elbow System
2.0, 2.8
APTUS
Elbow
®
2 | Elbow System 2.0, 2.8
 www.medartis.com/products/aptus/elbow
Elbow System 2.0, 2.8 | 3
Elbow System
2.0, 2.8
Contents
4 - 5
Features, Technique
6 - 13Introduction and Indications
6Introduction
6
Product materials
6Indications
6Contraindications
6Color coding
7 - 8Radial Head Plates
9 - 11
Olecranon Plates
12 - 13 Distal Humerus Plates
14 - 25 General Instrument Application
14 - 16 Bending
17Drilling
18 Thread preparation
19 - 20 Surgical technique lag screws
21
Determination of depth
22
Screw pick-up
23 - 25 Aiming Device
26 - 39Step-by-Step Instructions
26 - 27Radial Head Plates
28 - 30 Olecranon Tension Plate
31 - 33 Olecranon Neutralization Plates
34
Proximal Ulna Neutralization Plate
35 - 39 Distal Humerus Plates
40 - 41Correct application of the TriLock locking technology
Medartis, APTUS, MODUS, TriLock, HexaDrive and SpeedTip are registered trademarks
of Medartis AG, 4057 Basel, Switzerland
Features, Technique
Combination is the Solution
1
2
3
4
5
1CAD model with elbow plates
2
Detail - radial head plate
3Radial head plate with screws
4
5
Olecranon tension plate on bone model
Finite elements representation of a Medartis
plate
For further information on the plate range, see the APTUS Ordering Catalog at www.medartis.com/meta/downloads/marketing-materials.
• Multidirectional (±15°) and angular stable TriLock
locking technology
• Anatomic plate designs
• HexaDrive interface with excellent self-holding properties
Technology
•
Multidirectional (±15°) and angular stable TriLock
locking system
TriLock screws
can be re-locked
up to three times
o Spherical three-point wedge-locking
o Friction locking through radial bracing of the screw head
in the plate – without additional tensioning components
•
TriLock screws can be re-locked in the same plate hole
under individual angles up to three times
•
Minimal screw head protrusion thanks to internal locking
contour
•
No cold welding between plate and screws
•
Intra-operative fine tuning capabilities
Variable angle of ±15°
Plate Features
•
Anatomically pre-contoured plate design
•
Low overall profile height
•
Rounded edges and polished surfaces for maximum soft
tissue protection
•
Plates may be bent for a wide range of applications
Excellent
self-holding properties
Screw Features
•
HexaDrive – the optimal self-retaining mechanism between
screw and screwdriver for increased torque transmission
•
Precision cut thread profile for improved sharpness and
self-tapping properties
Contact surface for torque
transmission
Contact surface for
screw retention
Introduction and Indications
INTRODUCTION
Indications
Multidirectional and angular stable treatment for the elbow
•
The APTUS Elbow products provide an optimal selection for
the treatment of fractures, osteotomies and pseudarthroses.
osteotomies
•
The anatomic plate designs result in a highly precise fit. The
unique TriLock technology allows stabilization and bridging
Management of proximal radius fractures and
Management of fractures and osteotomies of the
proximal ulna
•
of unstable zones in accordance with the “fixateur interne”
Management of fractures, osteotomies and non-unions of
the distal humerus
principle. Multidirectional screw positioning helps to fixate
angular stable bone fragments, allowing for perfect anatomical
reconstruction. As a result of the enhanced self-retaining
HexaDrive screw holding properties, the screws are securely
Contraindications
held by the screwdriver. The combination of intuitive
sophisticated instrumentation results in an extremely user
•
friendly system.
implantation site
•
Known allergies and/or hypersensitivity to foreign bodies
•
Inferior or insufficient bone quality to securely anchor the
•
Patients who are incapacitated and/or uncooperative
Product Materials
implant
All APTUS implants are made from pure titanium (ASTM
F67, ISO 5832-2) or from titanium alloy (ASTM F136, ISO
Pre-existing or suspected infections at or near the
during the treatment phase
•
The treatment of at-risk groups is inadvisable
5832-3). All of the titanium materials used are biocompatible,
corrosion-resistant and non-toxic in a biological environment.
K-wires consist of stainless steel (ASTM F 138); Instruments
Color Coding
consist of stainless steel, PEEK or aluminum.
System Color Code
APTUS 2.0 blue
APTUS 2.8 orange
Plates and Screws
Special implant plates and screws have their own color:
Blue implant plates:  www.medartis.com/products/aptus/elbow
TriLock plates (locking)
Gold implant screws: Cortical screws (fixation)
Blue implant screws: TriLock screws (locking)
1. Radial Head Plates
The radial head plates can be used for fractures and
osteotomies of the proximal radius, in which internal fixation
with plates is indicated. The plates should be placed in the
Safe Zone
View on the articulation
of the radial head from
proximal.
Right radius in neutral
position.
so-called “Safe Zone” whenever the fracture pattern allows it
(c. picture).
The radial head plates exist in two versions, the rim plate
A-4656.68 and the buttress plate A-4656.69.
The radial head buttress plate has the advantage to spare the
annular ligament and enables the buttressing of a fracture
with comminution in the neck region.
Radial Head Rim Plate
For the stabilization of
complex comminuted
fractures
The radial head rim plate lies in part under the annular
ligament, but gives the possibility to treat complex fracture
patterns of radial head by internal fixation. In particular, the
orientation of the plate screw holes of the rim plate make it
possible to place bicortically subchondral screws in the most
proximal screw range that are parallel to the humeroradial
joint surface. This enables an optimal angular stable bridging
of a zone of comminution.
Radial Head Buttress
Plate
For an optimal sparing of
the annular ligament
Plate Features
•
Minimal plate thickness
•
Chamfered plate contour to minimize soft tissue irritation
•
Anatomic plate design
•
TriLock – multidirectional (±15°) and angular stable screw
locking is possible in each plate hole
•
All plate holes can be utilized with either locking or
non-locking screws
•
Consistent screw size (Ø 2.0 mm)
•
Titanium Grade 4 for optimal stability
•
Holes for supplemental 1.2 mm K-wire fixation
Clinical Benefits
Anatomic design to minimize soft tissue irritation and ensure
stable fixation
•
Anatomically optimized plate designs
•
Fixation of multiple fragments
•
Low plate profile minimizes soft tissue irritation particularly in
the case of the annular ligament
Multiple locking options
• Multidirectional and angular stable TriLock technology provides
a variable cone of ±15 for optimal fixation of all fragments
• Angular stability of screw fixation minimizes risk of postoperative loss of reduction
• Screw configuration can be adapted to the fracture pattern due
to numerous plate holes
2. Olecranon Plates
We distinguish in the following two fracture and plate types:
A. Fractures with inter-fragmentary support
 Olecranon Tension Plate
B. Fractures without inter-fragmentary support  Neutralization Plates
The Olecranon Tension Plate is intended to replace the classical
tension band wiring, is very thin entailing limited hardware
prominence and can only withstand tension forces.
Olecranon Tension Plate
The Neutralization Plates integrate increased bending
stiffness and are suitable for angular stable “bridging” of
comminuted fracture zones. The Medartis neutralization
plates are placed as a pair laterally and medially to the
dorsal rim of the proximal ulna, which is the favorable
position from the biomechanical standpoint. Medartis offers
two types of neutralization plates to address various fracture
patterns:
B.1 Proximal fractures of the proximal ulna
 Olecranon Neutralization Plates
Olecranon Neutralization Plates
B.2 Distal fractures of the proximal ulna
 Proximal Ulna Neutralization Plates (PUNP)
In the case of the neutralization plates, at least two screws
should be placed in each fragment for both plates.
Proximal Ulna Neutralization Plates
The Olecranon Neutralization Plates are to be used if the fracture pattern is so proximal that the proximal part of the plates
must surround the tip of the olecranon, entering the insertion of
the triceps tendon.
The Proximal Ulna Neutralization Plates can be used if the
fracture pattern is distal enough that the proximal part of the
plates do not have to go around the olecranon tip, thus sparing
the insertion of the triceps tendon.
In the case of the three fracture patterns, the following articles
have to be used:
1. Olecranon Tension Plate 
1x A-4856.01
2. Olecranon Neutralization Plates

1x A-4856.10 3. Proximal Ulna Neutralization Plates 
+ 1x A-4856.11
2x A-4856.12
Because the Olecranon Neutralization Plates become to lie
around the tip of the olecranon, they are already pre-contoured.
Additionally, the most proximal hole is laterally angulated, on
the right side for A-4856.10 and on the left side for A-4856.11.
This angulation assures that the most proximal holes do not
abut one another behind the olecranon and that the two small
incisions in the insertion of the triceps tendon can be parallel to
the muscle fibres. The two plates should therefore be optimally
placed as it is shown in the figure on the right if possible.
The olecranon plates have several holes for temporary fixation
with K-wires of diameter 1.6 mm.
A-4856.01
A-4856.10
A-4856.11
A-4856.12
Plate Features
•
TriLock – multidirectional (±15°) and angular stable locking
•
Neutralization plates are placed laterally to the ulna (biomechanical
advantage leads to smaller plates)
•
Uniform screw size (Ø 2.8 mm)
•
Plate thickness 0.5 mm (tension plate) and 1.6 mm (neutralization
plates) made of Titanium grade 4 for high stability
•
Anatomical plate design and easy contourability
Clinical Advantagess
Tension Plate
•
More stable fixation with tension plate compared to classical
tension band wiring even in borderline cases
•
No K-wire migration
•
No irritating wire knots
Neutralization Plates
• Less soft tissue irritation due to very low profile plates
• Plates can be covered by muscle tissue
3. Distal Humeral Plates
Three plate types are designed for internal fixation of distal
humeral fractures with the following plate positions:
1. Medial position
2. Lateral position
3. Posterolateral position
All plates are available in two lengths and in a left and a right
version, have a compression hole and several holes for temporary
fixation with K-wires of diameter 1.8 mm.
Medial
Lateral
Posterolateral
The plates can be used as a pair in the case of bicolumnar
fractures, either in a 90° (perpendicular) or in a 180° (parallel)
configuration as is illustrated in the figure.
90° Configuration
The aiming device A-2096 facilitates the placement of the
screws in the region of the articulation, in particular in the cases
of long screws between the epicondyles, because the exit point
of the screws is precisely fixed before drilling.
Please refer to page 19 for the handling.
180° Configuration
Plate Features
•
Multidirectional angular stability ±15° (TriLock)
•
Optimized anatomical plate shapes
•
Contourable for best fit to individual anatomy
•
3 plate types for 90°- and 180°-configuration
•
Low plate profile
•
Tapered plate thickness at the plate ends (ca. 1.6 mm),
maximum plate thickness in the fracture zone (ca. 3 mm)
•
Chamfered plate borders
•
Oblong hole and compression hole in every plate
•
Unique system size 2.8
•
K-wire holes Ø 1.8 mm
•
Lateral plates with twist for posterior position on the proximal side
(cf. figure on the right above)
•
Medial plates with recess to protect the the ulnar nerve (cf. figure on
the right below)
•
Posterolateral plates with pre-angled distal holes and flap
•
Aiming device for the placement of long screws in the distal
periarticular bone
Clinical Advantages
•
Stable fixation due to locking technology
•
Anatomical plate shapes facilitate anatomical reduction
•
90°- as well as 180°-configuration possibles
•
4 long screws can be placed in the distal subchondral bone between
the epicondyles and locked within the plates
•
Minimal soft tissue irritation due to anatomical plate design,
especially around the epicondyles
•
Stress risers in the bone avoided due to decreasing thickness of the
proximal plate ends
•
Sparing of the ulnar nerve due to a recess in the medial plates
•
Less soft tissue detachment and easier screw placement thanks to
posterior position of the proximal part of the lateral plates
•
distal fragments of the capitulum can be easily reached due to the
pre-angulation of the distal screw holes of the posterolateral plates
•
Flap of the posterolateral plates enable the connection of the long
subchondral screws to the plate
•
Atraumatic screw tips prevent soft tissue irritation when inserting
screws bicortically
•
Unique system size and easy-to-handle instruments facilitate surgery
General Instrument Application
Bending
If required, TriLock radial head plates can be bent with the
plate bending pliers A-2040 or A-2047.
TriLock olecranon plates and the lateral flap of the posterolateral distal humerus plates can be bent only with the plate
bending pliers A-2047. These plate bending pliers have two
different pins to protect the locking holes of flat and curved
A-2040
1.2-2.3 Plate Bending Pliers, with Vario Pin
plates during the bending process.
A-2047
2.0-2.8 Plate Bending Pliers, with Pins
A-2040
The labeled side of the plate must always face upward (“UP”)
when inserting the plate into the bending pliers.
A-2047
When bending a flat plate (olecranon plate) or the flap of the
posterolateral plates, the plate bending pliers must be held so
that the letters “F – FLAT PLATE THIS SIDE UP” are legible
from above.
When bending a curved plate (radial head plate), the letters
“C – CURVED PLATE THIS SIDE UP” must be legible from
above. This ensures that the plate holes are not damaged.
While bending, the plate must always be held at 2 adjacent
holes to prevent contour deformation of the intermediate plate
hole.
Do not bend the plate by more than 30°. Bending the plate
further may deform the plate holes and may cause the plate to
break postoperatively.
Note:
Repeated bending of the plate in opposite directions may
cause the plate to break postoperatively. Always use the
provided plate bending pliers to avoid damaging the plate
holes. Damaged plate holes prevent correct and secure seating
of the screw in the plate and increase the risk of system
failure.
A-2090
With the help of the bending irons A-2090, the distal humerus
plates can be bent or twisted out of to the plate plane or
they can be twisted.
A-2090
Plate Bending Irons Elbow
The medial and lateral distal humerus plates are to be bent in
the open slits “med” and ”lat”, resp., out of the plate plane
and to be twisted in the closed slits ”med” and “lat”, resp. The
posterolateral distal humerus plates are both to be bent and
twisted in the open slit “post-lat”.
Drilling
Color-coded twist drills are available for every APTUS system
size. All twist drills are color-coded via a ring system.
System size 2.0 = blue, 2.8 = orange.
Core Hole Drills = one colored ring
There are two different types of twist drills available for every
system size: one for core holes (one colored ring) and one for
gliding holes (two colored rings) (lag screw technique,
cf. page 19).
Gliding Hole Drills = two colored rings
The drill must always be guided through the drill guide
A-2620/A-2820 to prevent damaging the plate hole and to
protect surrounding tissue from direct contact with the drill.
A-2620
2.0/2.3 Drill Guide
A-2820
2.8 Drill Guide
The drill guide also serves to limit the drilling angle (±15°).
After positioning the plate, insert the drill guide into the plate
hole and the twist drill into the drill guide.
Note:
For locking plates ensure that the screw holes are predrilled
with a pivoting angle of up to ±15°. For this purpose, the drill
guides show a limit stop of ±15°. A pre-drilled pivoting angle of
< ±15° guarantees that the TriLock screws lock correctly into
the plate.
Thread Preparation with the Tap
All Medartis screws are self-tapping. In the case of very hard bone,
especially in the shaft region of the distal humerus, it can be
indicated to reduce the insertion torque of the 2.8 mm screws by
A-3839 2.8 Tap
using the 2.8 tap A-3839.
An unusually high resistance during the drilling of the core hole
and / or an unusually high insertiion torque of the screw can be
signs of a particularly hard bone requiring prior tapping.
After drilling a core hole with a 2.8 core hole drill (1 orange ring),
create a thread in the hole by using the 2.8 tap A-3839 together
with the handle A-2070 (or A-2073).
Then insert the screw with the corresponding screw driver (Screw
driver blade A-2013 with handle A-2070 (or A-2073)).
A-2070 (A-2073) Handle with AO coupling (canulated)
Lag screw techniques
Two lag screw techniques can be used, depending on the
implant.
A) Lag screw technique using cortical screws
The procedure for the lag screw technique using cortical screws
(A-5400.xx or A-5800.xx) is as follows:
1. Drilling the gliding hole
Use the gliding hole drill (two colored rings) to drill the gliding
hole through the end of drill guide A-2620 (2.0 mm) or A-2820
(2.8 mm) labeled ‘LAG’.
2. Drilling the core hole
Place the other end of the drill guide A-2620 (2.0 mm) or
A-2820 (2.8 mm) into the drilled gliding hole and use the twist
drill for core holes (one colored ring) to drill the core hole.
3. Compressing the fracture
Compress the fracture with the screw of the corresponding size.
4. Optional steps before compression
If required, use the countersink A-3835 to create a recess in the
bone for the screw head.
We recommend: Use the handle A-2070 instead of a power
drive.
B) Lag screw technique using lag screws
For lag screws A-5830.xx (2.8 mm) with partially threaded
shafts/necks, it is sufficient to drill a core hole using the drill
guide A-2820 and the core hole drill A-3832 or A-3837 (one
orange ring) and to insert the screw.
1. Drilling the core hole
Place the end of the drill guide (one colored marking) onto the
bone and use the core hole drill (one colored ring) to drill the
core hole.
2. Compressing the fracture
Compress the fracture by the use of a lag screw.
3. Optional steps before compression
If required, use the countersink A-3835 to create a recess in
the bone for the screw head.
We recommend: Use the handle A-2070 instead of a power
drive.
Washer
If the cortical bone is soft, the washer A-4750.70 can be used
for 2.8 mm cortical or lag screws in order to distribute the lag
forces over a larger surface of the bone around the screw hole.
Determination of Depth
The depth gauge A-2032 is used to determine the optimal
screw length for monocortical or bicortical screw fixation in
A-2032
2.0/2.3 Depth Gauge
the case of 2.0 mm screws.
The depth gauge A-2836 is used to determine the optimal
screw length for monocortical or bicortical screw fixation in
the case of 2.8 mm screws.
A-2836
2.8 Depth Gauge
To determine the screw length, place the tip of the depth
gauge into the implant plate or directly onto the bone.
The caliper of the depth gauge has a hooked tip that is either
inserted to the bottom of the hole or is used to catch the far
cortex of the bone to determine the correct screw length,
whereby the needle remains in place and only the slider is
moved.
A scale on the depth gauge shows the ideal screw length for
the measured drill hole.
Screw Pick-Up
The screwdriver A-2610 with the driver size HD6 is to be used
for the screws of size 2.0 mm. The handle A-2070 together
with the screw driver blade A-2013 of the driver size HD7 is to
A-2610
2.0/2.3 Screwdriver, self-holding, HD6
be used for the screws of size 2.8 mm.
Both A-2610 and A-2013 feature the patented HexaDrive
A-2013 / A-2070
self-holding system.
2.5/2.8 Screwdriver Blade, self-holding, HD7, with handle
To remove the screws from the implant container, vertically
insert the appropriately color-coded screwdriver into the screw
head of the desired screw with axial pressure and lift the screw
out of the container.
Note: The screw will not hold without axial pressure!
Vertically extract the screw from the compartment. The screw
is held securely by the blade.
If self-retention between screwdriver and screw cannot be
achieved despite being picked up correctly, usually the screw
has already been picked up. This often leads to a permanent
deformation of the self-retaining area of the HexaDrive inside
the screw head.
Check the screw length and diameter with the scale of the
measuring module. The screw is measured including its head.
Elbow System 2.0, 2.8 | Target tip
23
Drill Guide with drill stop
Aiming Device A-2096 for Distal Humerus Plates
The aiming device A-2096 facilitates the placement of the
screws in the region of the articulation, in particular in the
”Release” handle
case of long screws between the epicondyles, because the
exit point of the screws is precisely fixed before drilling.
The device is designed in a way that the drilling stops when
the drill bit A-3837 arrives at the target tip at the second
cortex of the bone.
Trigger handle
The length of the bicortical screw hole can be read on the
scale of the axle of the aiming device.
Position the target tip of the aiming device at the place
where the screw should exit (on the left in the picture). The
drill guide (on the right in the picture) of the aiming device
can be positioned in the plate hole in which the screw
should be placed by gripping the trigger handle. This reduces
the distance between the target tip and the drill guide until
both are in contact with the bone or the plate, respectively.
The device also exerts a slight compression on the fracture.
By gripping the trigger handle, the distance between the
target tip and the drill guide is reduced.
Trigger Handle
By pushing the “Release” button, the distance is increased.
”Release” handle
The drill bit A-3837 is inserted into the drill guide of the
aiming device and the hole can be drilled. The drill bit is
Drill Guide
with drill stop
stopped just before it reaches the target tip.
Note:
The drill guide is connected to the aiming device via a
left-hand thread.
When the device is in position, the screw length can be read
Axle with scale
on the scale on the axle.
Read value
Assembly of the Aiming Device
The aiming device A-2096 consists of the components
A-2095.1-4 and the components are stored individually
in the container module in order to assure an optimal
sterilization.
Numbers of the components
A-2095.1 Frame with handle
A-2095.2 Drill Stop
A-2095.3 Trigger with Target Tip
A-2095.4 Drill Guide 2.8
Step 1
Insert the drill guide 2.8 A-2095.4 into the frame with
handle A-2095.1.
Note:
Left-handed thread!
Step 2
Insert the axle with drill stop A-2095.2 into the frame with
handle A-2095.1.
Note:
Slightly lift the handle “Release” while inserting the
A-2095.2
Step 3
Insert the trigger with target tip A-2095.3 into the frame
with handle A-2095.1.
Note:
The axle with drill stop must be totally inserted before the
trigger with target tip A-2095.3. A slight “click” should be
heard at the end of insertion.
Step-by-Step Instructions
Radial Head Plates
Choose the radial head rim plate A-4656.68 or the radial head
buttress plate A-4656.69 depending on the fracture pattern
(cf. page 7).
Please refer to pages 11-21 for more details concerning the
use of the instruments employed in the following.
Reduce the fracture and apply the plate temporarily in order
to evaluate the necessity of bending of the plate. Position the
plate whenever possible in the “Safe Zone” (cf. page 7).
If necessary, bend the plates with the bending pliers A-2040
or A-2047.
Especially in the case of the buttress plate A-4656.69, the
bending of the plate bars in the neck region (cf. figure) can
optimize the plate position more or less distally from the joint
surface depending on the fracture pattern and the individual
anatomy.
Fix the plate temporarily with K-wires of diameter 1.2 or
1.25 mm. Shorten the K-wires with cutting pliers if they hinder
the following steps.
Place a first cortical screw in the shaft region. This screw pulls
the plate against the bone in order to establish a close contact .
For this, drill a core hole with the help of the drill guide A-2620
and the core hole drill bit A-3434 through the corresponding
plate hole.
Determine the screw length with the help of the depth gauge
A-2032.
Pick up a cortical screw A-5400.xx of the determined length
with the help of the screw driver A-2610 and insert it into the
drilled hole.
Correspondingly, fill the remaining plate holes with locking
(A-5450.xx) or non-locking (A-5400.xx) screws wherever
the fracture pattern requires it. Place at least three screws in
the shaft and the head part of the plate in order to achieve a
sufficient stability. A distribution of the screws into the head
utilizing both proximal screw rows increases the stability of the
fixation.
The choice of locking screws generally result in a in a higher
construct stability, especially in the case of comminution or
compromised bone quality. A non-locking screw enables to
pull a fragment against the plate.
It is important due to the natural convergence of the screws
in the plate around the round radial head to take advantage of
the multi-directionality (±15°) of the locking and non-locking
screws (gold) in order to avoid screw collisions.
Olecranon Tension Plate
Fixation Principle
The Olecranon Tension Plate can be used in the case of simple
fractures or osteotomies with good inter-fragmentary support.
The fixation principle of the Tension Plate is derived from
classical tension band wiring. The primary fixation is achieved
by two parallel, fracture crossing, lag screws – connected to
the Tension Plate through the proximal plate holes - that take
the place of the K-wires in tension band wiring. These two
lag screws are protected against the forces of the triceps by
the Tension Plate that takes the role of the cerclage wire and
compensates the tension forces of the triceps.
The lag screws enable a precise final reduction and
compression of the fracture gap.
The two oblong holes of the plate serve to tighten the thin bars
of the plate, which is important that the plate can accomplish
its function. The remaining two screw holes serve for a secure
fixation of the plate distally.
Step-by-Step Instructions
Reduce the fracture/osteotomy with positioning forceps and
fix the fracture temporarily with a K-wire in axial direction.
This K-wire will also help later as a mechanical guide when the
fracture/osteotomy is compressed with the help of the first lag
screw.
Contour the plate by hand so that the two proximal holes fit
around the tip of the olecranon and that the distal holes come
to lie on both sides laterally to the dorsal rim of the proximal
ulna.
Make two small incisions into the triceps tendon on the
olecranon in order to be able to place the two proximal holes in
direct contact with the bone of the proximal fragment. These
incisions should be parallel to the muscle fibres.
Make sure that the plate lies tightly and symmetrically on the
dorsal rim of the proximal ulna.
Temporarily fix the plate with two K-wires (ø=1.6 mm) through
the K-wire holes. This ensures that the plate remains centered
on the dorsal edge of the ulna while inserting the long lag
screws in the next steps.
Drill a fracture crossing core hole (drill bit with 1 orange ring)
through the first proximal plate hole using the drill guide for
soft tissue protection. The direction of this screw hole should
be subchondral to the trochlear notch of the ulna (similar to
the direction of the K-wires in classical tension band wiring)
so as to enable the placement of the two parallel fracturecrossing screws. These screws should be bicortical.
Measure the length of the screw using the depth gauge
A-2031. Insert a lag screw (A-5830.xx) of the measured
length through this hole without tightening it. Repeat the
procedure with the second proximal hole and a second lag
screw.
Remove the two K-wires from the plate.
Close the fracture gap by carefully tightening the two fracturecrossing lag screws and exert a slight compression on the
fracture so as to complete the reduction.
Insure by contouring the plate with your fingers that the plate
lies tightly on the posterior part of the proximal ulna. Drill a
core hole (drill bit with 1 orange ring) through the longer of
the two oblong holes. This core hole should lie slightly more
distally to the middle of the oblong hole. Measure the length of
the screw using the depth gauge A-2031 and insert a cortical
screw (A-5800.xx) of appropriate length in this hole. Do not
tighten the screw yet.
To tighten the plate longitudinal plate bars, hook the pointed
reduction forceps A-7003 in the distal part of the same oblong
hole and engage the forceps crosswise on the other side of the
dorsal rim of the ulna. Tighten the reduction forceps until the
longitudinal plate bar lies flat on the ulna. Then tighten the
screw in the oblong hole.
Drill a core hole through the neighbouring plate hole and insert
a cortical or locking screw. A locking screw will provide more
stability. Tighten it.
Repeat these steps on the other side of the plate, completing
the fixation of the plate.
The small incisions in the triceps can be closed over the
proximal plate holes by a small suture on each side.
OleCranon Neutralization Plates
Fixation Principle
The Olecranon Neutralization Plates are intended for fractures
being so proximal that the plates must come to lie around the
tip of the olecranon in order to enable the placement of enough
screws in the proximal fragment. For this reason, the plates
are already pre-contoured in order to fit around the tip of the
olecranon.
Additionally, the most proximal hole is laterally angulated,
on the right side for A-4856.10 and on the left side for
A-4856.11. This angulation assures that the most proximal
holes do not touch behind the olecranon and that the two
small incisions in the insertion of the triceps tendon can be
parallel to the muscle fibres. The two plates should therefore
be placed as shown in the figure on the right if possible.
Step-by-Step instructions
Reduce the fracture. Temporary fixation of the plate K-wires of
1.6 mm possible.
Identify the optimal plate positions and make two incisions
into the triceps tendon on the olecranon in order to be able
to place the proximal part of the two plates on the proximal
fragment. The plates should lie laterally to the dorsal rim of the
proximal ulna and surround the olecranon tip without touching
each other. Open the muscle insertions on the distal fragment
in order to be able to place the plates laterally on both sides
of the ulna. The position of the plates should be lateral to the
dorsal rim of the proximal ulna, not too dorsal in order to spare
the dorsal rim and not too ventral in order to avoid an excessive
detachment of muscles and the contact with the ulnar and
radial nerves
Bend the plates with the bending pliers A-2047 in order to fit
the anatomy of the patient’s bone.
Temporarily fix each plate using a cortical screw A-5800.xx
in the oblong hole. This pulls the contoured plate against the
bone .
For this, drill a hole through the oblong hole with the help of
the drill guide A-2820 and the core hole drill bit A-3832.
Determine the optimal screw length using the depth gauge
A-2836.
Pick up a cortical screw (A-5800.xx) of the determined length
with the screw driver blade A-2013 and the handle A-2070 (or
A-2073) and insert it into the drilled hole.
Fill the remaining plate holes with locking (A-5850.xx) or nonlocking (A-5800.xx) screws wherever indicated by the fracture
pattern.
For each plate, set at least two locking screws distally and
proximally to the fracture so as to ensure a sufficient stability.
Take care that the screws in the proximal part are short enough to
not protrude into the joint surface. The other screws can be placed
bicortically for increased stability.
In the case of a fracture of the coronoid process with involvement
of the medial collateral ligament, one or two screws depending on
the fragment size can potentially be placed into the tuberculum
subliminum from the plate on the radial side of the ulna (cf. figure
on the right).
If possible, close the incisions of the muscle insertions by sutures
in order to restore the function of the muscle and to cover the
plates with muscle tissue.
Proximal ulna neutralization plate
Fixation principle
The Proximal Ulna Neutralization Plates are intended for
fractures that lie distally enough that enough screws can be
placed in the proximal fragment without the necessity to go
around the tip of the olecranon with the plates. The plates are
therefore straight because they can be contoured easily with
the help of the bending pliers A-2047 to the lateral bow of the
proximal ulna.
Step-by-Step instructions
In analogy to the preceding section
Distal Humeral Plates
Reduce the fracture. All plates can be temporarily fixed with
1.8 mm K-wires on the bone and a compression hole can be
used to exert compression on the fracture (cf. page 39).
In both cases of 90° or 180° configuration, place a medial
plate on the medial side of the distal humerus. The plate can
be fixed temporarily on the bone with 1.8 mm K-wire.
If necessary, contour the plate with the bending irons A-2090
in order to achieve an optimal fit to the individual anatomy of
the patient.
In the case of a 90° configuration, place a posterolateral
plate on the posterior side of the lateral column of the distal
humerus.
If necessary, contour the flap of the plate with the help
of the bending pliers A-2047 so that it fits the lateral
epicondyle. This flap can also be removed using cutting
pliers. The bending irons must be held that the inscription “F”
corresponds to the upper side of the plate (cf. figure on the
right).
In the case of a 180° configuration, place a lateral plate on the
lateral side of the distal humerus. The lateral plate is designed to lie
truly laterally on the lateral epicondyle, but has a twist that brings it
proximally in the shaft region on the posterior side of the humerus.
If necessary, adapt the plate to the individual anatomy by using the
bending irons.
In all plates, the use of the oblong hole enables the temporary
fixation of the plate on the bone and makes still possible a
subsequent adjustment of the plate position in axial direction.
For this, drill a core hole through the oblong hole using the drill bit
A-3832 (1 orange circle) and the drill guide A 2820.
Determine the screw length by measuring the depth of the hole
using the depth gauge A-2031.
Insert a non-locking cortical screw (gold) of the determined length
into the drilled hole with the help of the screw driver. If necessary,
the plate position can be adapted longitudinally after removal of the
K-wires in the plate by temporarily loosening this screw.
Place cortical or locking screws, depending on the fracture
pattern, into the plate screw holes where appropriate following
the previous instructions. If the fragment is to be reduced
against the plate, a cortical screw is necessary. Otherwise, a
locking screw is recommended to achieve greater stability of
the fixation.
Take advantage of the multi-directionality of the locking and
non-locking screws in order to fix the different fragments
against the plate where appropriate and to avoid screw
collisions, especially in the case of bicortical screw placement.
It is generally advantageous to direct two subchondral screws
from each epicondyle to the other side. Try to direct the screw
exit points in direction of the bone next to the joint surfaces of
the trochlea or the capitulum, respectively.
To facilitate the placement of these long screws, an aiming
device can be used. The sharp metallic point (on the left in
the figure can be set on the exit point and the drill sleeve on
the entrance point (on the right side in the figure). A slight
compression can then be exerted on the fracture with the
instrument. The drill bit A-3837 is guided by the drill sleeve
and thus the direction of the hole predetermined.
Angulated distal screw holes of the posterolateral plates
The two most distal screw holes of the posterolateral plates are
angulated for the following reasons:
- even very small distal fragments of the capitulum can be
reached and fixed against the plate
- the passage of the long subchrondral screws from the flap in
direction of the opposite epicondyle is made possible
Use of the compression hole
Each distal humeral plate has a compression hole (second
most proximal plate hole). It can be used if compression is to
be exerted on the fracture.
Insure that the fragments distal to the fracture line are
securely fixed against the plate.
Drill a core hole (drill bit with one orange circle) in the small
part of the eccentric compression hole and select a cortical
screw of appropriate length with the depth gauge. Insert this
cortical screw into the drilled hole without tightening it.
Remove all temporary K-wires and screws in the proximal part
of the plate and untighten the screw in the oblong hole, then
tighten the screw in the compression hole.
During the tightening of the screw in the compression hole,
the screw head glides from the small part into the large part of
the eccentric hole, which moves the plate in proximal direction
and exerts compression on the fracture.
Correct Application of the TriLock Locking
Technology
The screw is inserted through the plate hole into a pre-drilled
canal in the bone. An increase of the tightening torque will be
felt as soon as the screw head gets in contact with the plate
surface.
This indicates the start of the “Insertion Phase” as the screw
head starts entering the locking zone of the plate (section “A”
in the diagram). Afterwards, a drop of the tightening torque
occurs (section “B” in the diagram). Finally the actual locking
is initiated (section “C” in the diagram) as a friction connection
is established between screw and plate when tightening firmly.
The torque applied during fastening of the screw is decisive for
the quality of the locking as described in section “C” of the
diagram.
Rotational Angle α
Torque M
Locking Torque MLock
Insertion Torque MIn
Insertion
Phase
Release
Locking
A
B
C
Correct locking (±15°) of the TriLock screws
in the plate
Visual inspection of the screw head projection provides an
indicator of correct locking. Correct locking has occurred
only when the screw head has locked flush with the plate
surface (figures 1+3). However, if the screw head can still be
seen or felt (figures 2+4), the screw head has not completely
entered the plate and reached the locking position. In this
case the screw has to be retightened to obtain full penetration and proper locking.
Do not overtighten the screw, otherwise the locking function
cannot be guaranteed anymore.
Correct: LOCKED
Incorrect: UNLOCKED
Figure 1
Figure 2
Correct: LOCKED
Incorrect: UNLOCKED
Figure 3
Figure 4
ELBOW-01010001_v4 / © 11.2013, Medartis AG, Switzerland. All technical data subject to alteration.
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P +41 61 633 34 34 | F +41 61 633 34 00 | www.medartis.com
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APTUS® Elbow Elbow System 2.0, 2.8

Transcription

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